Study selection

Studies were selected if they were randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing an educational
intervention designed to teach ≥1 self management strategy related to prevention, attack management, or social skills with
usual care; measured objective outcomes; and patients were children or adolescents (2–18 y).

Meta-analyses of RCTs were done using a fixed effects model. Improvements in lung function and measures of self efficacy were
greater in the self management group than in the usual care group (table). The mean number of days absent from school and
mean number of visits to the emergency department were lower in the self management group than in the usual care group (table).
The groups did not differ for days of restricted activity, nights disturbed by asthma, asthma severity scores, number of exacerbations,
or visits to a general practitioner (table).

Evidence suggests that the global prevalence of asthma is increasing by as much as 50% every 10–15 years.1 Usually, asthma can be controlled so that an individual experiences minimal symptoms (cough, wheeze, shortness of breath)
and few disruptions in usual daily activities. As a result, the goal of asthma care guidelines internationally is to achieve
minimal experience of symptoms and disruption because of asthma while using the least amount of medication.1–4 Typically, core elements of asthma practice guidelines include confirming the diagnosis, providing appropriate medications,
using environmental control strategies to minimise or avoid exposure to triggers, and providing asthma education and support
for self management.1–4

Previous work by Gibson et al established that adults with asthma who receive self management education, RMR, and a written action plan show important
improvements in asthma outcomes, such as use of healthcare services (emergency department visits and unscheduled doctor visits),
days lost from work, nocturnal asthma, indirect costs, and quality of life.5 Furthermore, Gibson et al’s work highlighted the fact that less intensive education programmes are not as beneficial,5–6 specifically programmes that provide only patient information. The reviews by Wolf et al and Powell and Gibson extend our current understanding of key aspects of asthma care, education, and self management.

The review by Powell and Gibson suggests that optimal asthma control in adults, through the adjustment of medications, can
be achieved equally well using either a written action plan or RMR. Furthermore, the action plan can be based on symptom experience
alone or peak flow measurements plus symptoms. This finding is important because it shows that patients have the ability to
self adjust medications according to a written plan developed in conjunction with asthma care providers. Thus, individuals
who prefer to be more actively involved in their own care can adjust medications as a stepped course of action without seeking
medical assistance.

An action plan is a written set of instructions that helps patients to self monitor the level of asthma control through symptom
experience and/or peak flow measurements and outlines steps to maintain or regain asthma control. The action plan sets individual
parameters for monitoring asthma control and steps to respond to the level of asthma control, such as increasing the dose
of inhaled corticosteroid, starting an oral glucocorticoid, or seeking medical attention. The importance of action plans or
self management plans for achieving optimal control is acknowledged in asthma care guidelines.1–4

The review by Wolf et al shows that the benefits of asthma self management programmes also apply to children and adolescents. All of the studies included
in this review provided action plans and education on asthma prevention and management of worsening asthma.

In summary, these reviews establish the importance of the recommendations of asthma care guidelines. Patients with asthma
should receive self management education and a written action plan, based on symptoms or peak expiratory flow, which is tailored
to individual needs. After determining a patient’s ability to follow an action plan and readiness to learn, nurses need to
ensure that each patient has an action plan that is understood and used appropriately, and that the recommended medications
are used with appropriate techniques. Asthma education should be regarded as a process, rather than a single event, with ongoing
reassessment and reinforcement at each encounter.